Defensor: PhilHealth loss to overpayment, fraud at P153.7-B from 2013 to 2018

MANILA, Philippines — Philippine Health Insurance Corp. (PhilHealth) lost an estimated P153.7 billion from 2013 to 2018 due to overpayment and fraud, Anakalusugan Partylist Rep. Mike Defensor said Tuesday.

During the hearing of the House hearing on public accounts on the alleged anomalies in PhilHealth, Defensor, who chairs the said panel, said that computed conservatively at 20 percent as set by the Commission on Audit (COA), the state-run health insurer has lost P102 billion due to overpayment.

Meanwhile, computed at 10 percent, Defensor further noted that PhilHealth has lost P51.2 billion due to fraud.

“Tinataya na P153 billion magmula 2013 na nagsimula and case rate to 2018 ang nawalang pondo sa PhilHealth,” Defensor said.

Defensor explained that the case rate system began in 2011, with another circular released  in 2013.

“Taong 2013, ginawa nila, sa isang circular na ang lahat ng pagbayad ng Philhealth na hindi na fee for service,” Defensor said.

“Ano ba yung fee for service? Kapag ikaw nagkasakit, gumastos ka ng P5,000, ipagpalagay natin na pneumonia, ang ginastos mo ay P5,000 lamang. Pero dahil ang case rate o ang case-based payment nila ay P15,000, babayaran pa rin ang hospital ng P15,000,” the lawmaker explained.

The lawmaker said this is where the government is losing its money.

During a Senate hearing on Monday, PhilHealth president Ricardo Morales said that about P10.2 billion from PhilHealth’s budget was “potentially lost” to fraudulent transactions and schemes in 2019.

This loss could balloon to P18 billion by next year if not addressed properly, he added.

/MUF